For today’s Compliance Conversations podcast, I’ve got a special treat for you: Dr. Ira Specter. He spent many years as a practicing OBGYN physician and is also a certified coder and medical auditor. After practicing medicine for a few decades he went on to run a large medical management company, where they did billing collection, coding, compliance, and ICD-10 courses for sixty-five physicians. Because of his unique perspective, we tackled bridging the gap between coding and auditing and physician documentation.
When asked what the biggest area for improvement for physician documentation is Dr. Specter said, “Let me start by saying, by and large, most physicians are under coding...If you look at what physicians do, if you take the amount of work a physician puts into seeing a patient, I’m sure there are exceptions, but most of the time physicians want to take good care of their patients. So, they put the time in, they put the effort in, they put all their education behind it. So, the level of care is usually very high. Now, what happens is, the level of documentation seems to be lower.”
It seems, according to Dr. Specter, that physicians are “cutting off their own legs,” and also “cherry picking” codes which hurt an organization’s bottom line, physicians, and might even be illegal in certain cases. What does it all mean?
Tune into my most recent episode of the Healthicity podcast, Compliance Conversations: The Psychology Behind Why Physicians Undercode, to find out what Dr. Specter views as the biggest mistakes physicians are currently making and learn what coders and auditors should look out for in physicians documentation, why physicians should never cherry pick codes, and the pitfalls of copying and cloning.
CJ: Hello everybody, welcome to another episode of Compliance Conversations. I’m CJ Wolf, the Sr. Compliance Executive at Healthicity, and today I have a wonderful guest, Dr. Ira Spector. Dr., welcome!
Ira: Thank you, thank you. It’s always nice talking with you.
CJ: Glad that you’re here, now. For our listeners, Dr. Specter is a physician, many, many years, a practicing physician, but he’s also a certified coder and certified medical auditor. We’ve chatted a few times, and I thought this would be great if we could get Dr. Specter on the phone, and on our podcast because I think he’s got a lot of unique perspectives and experience, so thank you so much for joining us.
Ira: Yeah, and also, it’s important that I spent a good twenty-five, thirty years in the trenches seeing patients, taking care of patients, being up at night. I was in obstetrics and gynecology. Then for fifteen years, the last fifteen years of my practice, I ran a large medical management company, where we had over sixty five physicians, in all specialties, where we did their billing collection, their coding, compliance, we gave them ICD-10 courses. I’ve had experience at both ends. It makes it a little unique, especially when I get to review compliance physicians who have been audited by Medicare or an insurance company. It really gives me a different perspective.
CJ: Yeah, Ira, that’s really what caught my attention when we were speaking originally. You have two careers almost. You had this amazing career as a practicing physician, and then you did for others what you were doing for yourself in trying to help others manage that whole medical maze, if I can say that, of coding, billing, office management and all of that. Like you said now, rebuttal audits and those sorts of things, when people say that the Dr.’s have not coded right or have not provided services correctly. Absolutely that is such a great background. With that kind of in our minds, you are a physician, you’re often reviewing coding and documentation of other physicians. In a general sense, I know there can be specifics. In a general sense, what can you say is the biggest area for improvement, that you’ve noticed, if you could talk to all physicians at once, and there were one or two major general areas for improvement, what would you say, for their documentation.
Ira: Let me start by saying, by and large, most physicians are undercoding.
Ira: Okay, if you look at what physicians do, if you take the amount of work a physician puts into seeing a patient, I’m sure there are exceptions, but most of the time physicians want to take good care of their patients. So, they put the time in, they put the effort in, they put all their education behind it. So, the level of care is usually very high. Now, what happens is the level of documentation seems to be lower. They don’t document, put down, what they actually had to go through, what they had to think about, what they had to consider, when they took care of this patient. That doesn’t go into the visit. Then what happens is either they have a computer programing doing coding, which invariably doesn’t do it right--either it over codes or under codes--or they have a coder, who has to go to what they wrote down and decide what medical necessity is the background, what the codes should be. I’ve gone into practices where the coders were told don’t code anything above a 3.
CJ: Right! The doc sells themselves short.
Ira: Right, they are just cutting off their legs. It’s bad. Now when you think about it, that is half, there is much more undercoding than overcoding, so what happens is, you look at the Medicare, you know the Medicare bell curve, with 99213’s 99214’s 99215’s, they compare physicians that bell curve. The problem is the data that went into the bell curve, is probably a lot, a lot, of undercoding. People don’t realize they take the curve as what the norm should be, and I don’t really think it is. Do I have actual proof, no.
CJ: But in your experience in working with and looking at clients, would you say that, and again this is general, that a lot of their level 3’s should be 4’s, their 2’s should be 3’s, what are those specific area’s that you see?
Ira: Okay, the most important thing, what we’ve learned running a management company, is that our job got much, much easier when we gave the physicians a course on coding and documentation.
CJ: Yeah, I believe it.
Ira: It is. So, what happens usually, especially if most of them are on EHR’s now . . .
Ira: They plug in, or they copy over, clone the same thing from the previous visit, without updating or noting that it was updated--and I’ll talk about that in a minute--and then they write some stuff, but they don’t go through, especially the decision making, what went through their mind, what they had to consider. Okay. In taking care of this patient.
Ira: When I talk to any physician, I don’t care if it’s a dermatologist, a surgeon, even an ophthalmologist, especially primary care, if you get a new patient, if you’re a dermatologist, and you don’t do a head to toe, a general review assistance, a head to toe examination, on a new patient, you’re amiss. I don’t care what kind of Dr.; we all learn in medical school how to do an examination. If you have a new patient, I don’t care what your specialty is, if you’re GI, you have to do a complete history, you have to do a head to toe physical. As a gynecologist I’ve picked up thyroid tumors, thyroid cancers, I mean, it is really important to examine the whole patient. So new patient visits, the history and physical should, by and large, be a comprehensive, initial comprehensive, on every new patient you see. Unless you’re in a walk-in clinic or someplace you are taking care of hangnails or something. I mean, you still need to know the patient’s diagram, if they have allergies etc., or what medications. There are certain things that you need to do, so a big mistake that they Dr.’s make, is that they don’t do this on the initial.
Ira: On revisits, when the patients come back with other problems, the two biggest opa’s is not putting in, in the reason for coming in, the true medical necessity. I like to talk about, to the physicians that I counsel and teach, give teaching sessions to, sometimes in groups, sometimes one on one, is what I call ‘by the way . . .’.
CJ: “By the way”?
Ira: "By the way," I call it by the way. What by the way is is when a patient comes in, say you're a primary care, a patient coming in for their annual physical, not the annual medical full visit, but the annual physical, okay, there is a difference. Most physicians don’t understand that. They're coming in, say, for their physical, and they have high blood pressure, and halfway through the exam, the patient goes “Oh, By the way Dr., I have this…”, alright?
Ira: Say the patients coming in, during a global period of surgery, or to check up on another item where it’s a revisit, not a new problem, and they add something, that is a separate incident, and that has to be put down. It’s got to go into the HPI, and into the reason for why they come in, and say in addition the patient also complains of, and describe it. Now that is another item, it had nothing to do why they came into the visit for a blood pressure check, or something else.
CJ: Yeah, I like the way you put it as a ‘by the way’, that’s a good way for the physicians to remember. It happens all the time.
Ira: That’s what happens! "By the way, Dr., while I’m here, can you check . . ."
Ira: And that is a separate, use the 25 modifier, and you can actually bill for it. Now, that’s another thing. I always told my physicians you bill for what you do, you don’t bill for what insurance companies will pay.
CJ: That’s right, they are two different things.
Ira: Right, totally different. So, if you do something, bill it. Even if you know this particular insurance company this patient has doesn’t pay it. For a number of reasons, one, you need to be specific, you can’t cherry pick. That can be considered illegal. Secondly, you never know when they will start paying it. I always tell the physicians, "You bill what you do."
CJ: Plus, you might think you know who the patient has for insurance but they might be in between jobs, they might have to apply for Medicaid, I mean, you don’t really know, and you shouldn’t be focused on what type of insurance they have. Like you said, you should treat all patients the same, bill it, and you let the reimbursement thing fall out on its own.
Ira: Right, exactly. You have to do just a little bit more write offs, because they don’t pay, that’s fine. You need to do that.
Ira: It’s very important. The other big thing that physicians do, they don’t… If they bring in, in the EMR’s the dualities are already there, the past history is there, what needs to be done, what needs to be done, you just can’t bring it in, what you have to do, you have to say, the past medical history, allergies, and social history was reviewed and updated.
Ira: Now, if you say the allergies were reviewed and updated and there was no change, you don’t need to include that in your notes.
CJ: That’s right.
Ira: But you need to say that, because, I don’t care what the medical necessity is, if you don’t check a patient’s allergies when they come in, you’re remiss.
CJ: That’s exactly right, because if they have something and you didn’t ask about it, you’re in trouble.
Ira: Right. This shows that you are doing it.
CJ: That’s right.
Ira: The next really biggest thing is in the medical decision making.
Ira: Now, you know you have the Medicare population, or any population that is over 40, 50, Medicare if they're over 65, you know that 70 or 80 percent have more than two medical, chronic medical, conditions.
CJ: That’s right.
Ira: Now, when you're doing decision making, you’re reviewing their medical history, their social history, their medication, you’re reviewing what happened recently, you may be reviewing lab material. You take a look at their, what they call their main screen, or their dashboard, whatever EMR calls it. You’re looking at the surgeries they have had, you're looking at . . . now all of this is review of information, but they Dr.’s don’t put it down.
Ira: When you do medical decision making, not only is the number of diagnosis important, the severity of the diagnosis, but also the amount of material that you need to review. Now, a lot of this is almost instantaneous in the Dr.’s mind . . .
CJ: That’s right, that’s why they don’t put it down, because it has become second nature to them.
Ira: Right, exactly, exactly. That’s a big mistake. It doesn’t take a lot to do this, all it does, it takes a second in the summery, the medical decision making portion, saying that, one sentence, this is all reviewed on this patient, and then this is what we’re going to do, these are the lab tests we’re going to order. Basically, what you’re looking for, and this all ties back to the medical necessity.
Ira: Now, one of the biggest things I’ve found, unfortunately, when insurance companies review doctors' visits . . . Let’s go back a step. A Dr. gets a request for thirty visits, not charged. What the usual Dr. does is say give this to the secretary, says here pull these visits, copy and then send them.
Ira: First big mistake.
CJ: They forget a lot of that peripheral information sometimes.
Ira: Well, what happens is there is no rule that says all the information, okay, must be in one place on the chart.
CJ: That’s exactly right. It must be in the medical record.
Ira: Exactly, so when the secretary just copies the portion from that day, without the other information that was mentioned or was used. Or, you know, there may be an allergy list on the back of the chart. You know, they are on a paper chart. So what happens is they don’t send in the right information, then of course they get told they want $300,000 back, and they can’t do it, so they first thing the Dr. has to do when they get that is have the nurse or have the secretary pull the patients's chart, or if it’s on electronics, you know, have it pulled up for the Dr. so the Dr. can review. Nothing should show out of the office before the Dr. reviews it.
CJ: That’s right.
Ira: The Dr. needs to review it, make sure that all the information that he can considers for the care of that patients for the care of that patient goes along with it.
CJ: That’s right.
Ira: If it’s a laser log on abrasions of lesions, whatever was associated with that visit goes with it, because that will solve half the problem. What will happen though, is they will deny everything.
CJ: That’s right, and half the supporting documentation is in the other material you’re talking about.
Ira: Right, exactly. The other thing that I came across is that I’ve had doctors actually recodes the visits, and send it back with the documentation, and you can’t do that.
CJ: No . . . No . . .
Ira: You just can’t do it. Alright, what I usually suggest, when, if they get these letters back with a bit of the down coding, and the extrapolation on what this Dr. owes, I think the last one was around $160,000 . . .
CJ: Was it a commercial insurer?
Ira: Yeah, commercial. It was interesting because the commercial insurer didn’t even have a coder review it, they had a nurse review it. The nurse was not a coder.
CJ: That’s a problem.
Ira: That is a problem. So, basically, there were about, how many charts . . . there were about fifty visits. I got all the information, we had to pull the visits, there were a lot of laser logs that were not included, a lot of information wasn’t included, I recoded it. What I did, I divided it into four categories, okay?
Ira: The first category was where the insurance company, the Dr., and me all agreed on the code being correct. So, everybody agreed. That was about 10 out of the 40 or 50. The next group was interesting, it was where I agreed with the insurance company, that the Dr. overcoded the visits based on medical necessity, and other things. About 10 or 12 charts, that, I’m a consultant, I have a reputation, I have to be honest and in a way, it actually helps get this done.
CJ: That’s right.
Ira: So, there were about 12 charts that I sent to the insurance company, I sent it in a list, these 12 charts, here’s my data, I agree with you, the Dr. over coded by this much on each one. That was the second group. The third group is where I agree with the physician and not the insurance company, and this group was interesting, because this insurance company, the medical necessity on those charts, around 15 charts, was all there, the documentation was all there, up to code. Mostly four codes. What they downcoded on was because the Dr. had indicated 9 instead of 10 review insistence. That is the only reason, based on medical necessity, this was a high level. I said I disagreed with this, I said you can’t do that. It’s based on medical necessity, the guidelines 95, or 97, guidelines are guidelines, they are not rules. They are guidelines and based on medical necessity this is absolutely wrong and unfair. That was the third one. The fourth group is where I didn’t agree with anybody. Most of that group, 8 or 9 charts in there, the Dr. and the insurance company under coded based on medical necessity. Okay?
Ira: What I did in my summery, I said, "Lsten, in my opinion as a physician, a coder, and an auditor, you have a physician here, on your insurance company, that see’s your patient, this is Medicaid and Medicare managed care, who is giving absolutely superior care to your patients. If you look at what we did here, it’s a wash."
CJ: Yeah, it’s a lot of time, though, and energy spent on that wash though, isn’t it?
Ira: Well, people get paid on what they collect, a lot of the wrap orders, it was in house insurance. I said you don’t want to lose this guy. If anything, you will owe him a few dollars. I said, I’m going to give this physician, we’re going to sit down, and we’re going to spend a few hours going over the documentation and coding, and he’ll be glad to have you review, again, some of his work, but I think you’ll find you have an excellent, excellent physician here, and the insurance company dropped the whole thing.
CJ: That’s a great story. We’re kind of coming towards the end of our time together, you obviously have a lot of interesting examples of how these Dr.’s is potentially losing out, and I really appreciate this last example of how it ends up being a wash. Do you have any last-minute comments or thoughts on this topic as we get ready to wrap it up?
Ira: Not a comment, I’ll say it again, the most important thing is to teach physicians coding and documentation. Giving them a basic course. It will solve a million problems going forward. The other thing that we really need to have a little talk on, in the future, is billing based on time. A lot of physicians will sit and spend an hour with the patient, taking care of a myriad of problems, and they end up billing a 2 or a 3, and this is unfair.
Ira: I think this is something that we really need to talk about.
CJ: Yeah, I think that is a really great point, and maybe that’s a topic for another day, I agree with you. I have met with, and I think it is probably true for a lot of physicians, especially the longer they are in practice. Their practice becomes more and more, supportive, and you’re explaining the risks and this and that, so you might not be doing history and medical decision making, but you sure are doing a lot of advising and counseling and coordinating care, and that is an element of time.
Ira: You can bill on it, and it’s perfectly legitimate, you’re giving the care. The Dr. that is giving the care needs to be paid for the care.
CJ: That’s exactly right. Dr. Spector, thank you so much for your time and your examples. Obviously there are a vast number of scenarios and examples we can discuss. We appreciate your expertise and your experience in this area.
Ira: Thank you, it was a pleasure being on your podcast, and I look forward to us talking again.
CJ: Well everybody, thank you for listening to another episode of Compliance Conversations. Until next time, happy compliance.